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Leveraging Network-Wide Opportunities to
Manage Population Health
Session 286, February 14, 2019
Richard T. Shirey, SVP and CIO, Hartford HealthCare
Isabella Veillette, Application Manager, Hartford HealthCare
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▪ Employees of Hartford HealthCare
▪ Hartford HealthCare is a client of Innovaccer
▪ Innovaccer has sole ownership and rights to their healthcare
data platform
Conflict of Interest
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▪ About us
▪ Problem statement
▪ Our solution illustrated
▪ Key outcomes
▪ Insights and lessons learned
▪ Critical success factors
▪ Q&A
Agenda
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▪ Describe the importance of integrating physicians in a network
spread across various geographies on multiple data systems
▪ Explain the importance of clinical data quality and its business
impact
▪ Illustrate a framework for connecting ambulatory sites on
different data systems and leveraging that connection to close
gaps in care, report on quality performance, and improve
overall outcomes
Learning Objectives
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▪ 6 hospitals
− 1,941 beds
− 80,536 inpatient transitions
− 381,630 ED visits
▪ Behavioral health network
▪ Home care network
▪ Rehabilitation network
▪ Senior care network
▪ Integrated Care Partners (ICP) clinically
integrated network
▪ 128 clinics
▪ 14 surgical and diagnostic centers
▪ 27 imaging locations
▪ 126 cities and towns in service area
▪ 15,000+ lives touched daily
Hartford HealthCare Background
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▪ 1,800 providers throughout eastern, central,
and northwestern Connecticut
− 300 primary care providers
− 1,100 specialty physicians
− 400 advanced practice clinicians
▪ 30 community care managers who assist
primary care providers in managing complex
and/or chronically ill patients
▪ 2 pharmacists who assist providers with
complex medication challenges
▪ 11 primary care behavioral health clinicians
embedded in 13 primary care locations
▪ 1,800 providers throughout eastern, central,
and northwestern Connecticut
− 300 primary care providers
− 1,100 specialty physicians
− 400 advanced practice clinicians
▪ 30 community care managers who assist
primary care providers in managing complex
and/or chronically ill patients
▪ 2 pharmacists who assist providers with
complex medication challenges
▪ 11 primary care behavioral health clinicians
embedded in 13 primary care locations
▪ 6 hospitals
− 1,941 beds
− 80,536 inpatient transitions
− 381,630 ED visits
▪ Behavioral health network
▪ Home care network
▪ Rehabilitation network
▪ Senior care network
▪ Integrated Care Partners (ICP) clinically
integrated network
▪ 128 clinics
▪ 14 surgical and diagnostic centers
▪ 27 imaging locations
▪ 126 cities and towns in service area
▪ 15,000+ lives touched daily
Hartford HealthCare Background
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Create Value
Quality
Performance
Manage the Total
Cost of Care
Growth of
Attributed Lives
& In-Network
Utilization
Manage Risk
Manage
Alternative
Payment Models
Coordinate
Care
Integrated Care
Management
Clinical Data at
Point of Care
Culture &
Capabilities
Change Provider
Decisions
ICP Strategic Priorities
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▪ Problem: Managing risk contracts and quality with limited clinical
information and no ability to measure or track performance on quality
measures across all ambulatory sites
− Members of our clinically integrated network (CIN) were utilizing 36
unique ambulatory EHRs across 102 practice locations
− Additionally, CIN members on the same EHR were utilizing different
versions with unique configurations for their practice
Barriers to Achieving Strategic Goals:
Data from Multiple Sources
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Data Integration: The Need of the Hour
▪ Solution: Integrating clinical and claims data into a single database using
standard data formats for analysis in a centralized performance platform
− C-CDAs for clinical data
− Pre-adjudicated claims (837s) for claims data
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Normalized
Database
CIN Members
ONC-certified EHRs
▪ Epic
▪ Athena
▪ NextGen
▪ Allscripts
▪ 30+ Others
Centralized
performance
platform
Provider /
Organization
Dashboards
Provider /
Organization
Dashboards
Extract
Export
Transmit
Illustrating the Solution:
A Centralized Performance Platform
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Creating an Integrated
Data Platform
Comprehensive data
platform with regular data
extraction and ingestion
from ambulatory practices
Obtaining and
Constantly Improving
Quality Data
Top quality data to create
actionable insights for
care managers,
providers, and leadership
Pushing All Data into
Epic to Create a Single
Source of Truth
Regular push into Epic’s
data warehouse and
utilization of Healthy
Planet tools to power
analytics and dashboards
A Three-Pronged Approach to Effective
Population Health
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QAIngestion Delivery
Clinical and
Financial Data
837 Integration
File Generation
Healthy Planet
Quality
Metrics
Analytics
Transforming Data into Insights
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Healthy Planet
Dashboards
Healthy Planet
Dashboards
Claims
Data
FTP
Patient
Attribution
Provider
Contract
Association
Genesis of an Intelligent Data Ecosystem
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Quality Data is the Foundation
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CPT Code
Description
Number of Missed/Blank Codes
97110
Physical Medicine & Rehabilitation
1958 times
90658
Influenza Vaccine
1931 times
97010
PT (Hot/Cold Packs)
1550 times
90670
Pneumococcal conjugates vaccine
490 times
ICD
-10 Codes
Description
Number of Missed/Blank Codes
E 78.0
Hyper Cholestrolemia
778 times
E 78.1
Hypertriglyceridemia
358 times
F 41.9
Anxiety Order
278 times
E 78.5
Hyperlipidemia, Unspecified
147 times
LOIN
-C Codes
Description
Number of Missed/Blank Codes
72514
-3
Pain Severity Score
777 times
8480
-6
Systolic Blood Pressure
754 times
8462
-4
Diastolic Blood Pressure
754 times
Effectively Managing Data Gaps to
Improve Quality Measure Performance
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Additional Use Case for Data:
Tracking Referral Patterns and Trends
Centralized
performance
platform
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▪ 15 ambulatory EHRs across 34 ambulatory practices
integrated since October 2017
▪ Over 1,000,000 C-CDAs delivered since February 2018
▪ Over 90,000 837s delivered since 2017
▪ Data Quality Reports generated in Innovaccer’s InData
platform highlighting invalid codes and data gaps
▪ Achieved interoperability with Epic’s Healthy Planet
▪ Deployed population health dashboards to MSSP practices
through Healthy Planet Link
Key Outcomes
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▪ Differences between what practices reported and what their
data reflected in regards to quality measure performance
Preparing for transition from audits via manual
abstraction to electronic attestation
Creating a culture of defensible data
▪ Physician resistance as a barrier to data integration
Emphasizing the importance of data integration to
physician alliance
Shifting thinking from self-attestation to reporting as
part of a larger group to realize benefits
Insights and Lessons Learned
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▪ Leveraging information from all practices across the network
to identify key opportunities
▪ Integrating all existing systems so that all information is
readily available, ideally in an intuitive format in a single
location
▪ Getting every provider on same page regarding the outcomes
of their patient population
▪ Engaging care teams by providing them with real-time
insights on their patients
Critical Success Factors
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▪ Contact information
− Richard Shirey: Richard.Shirey@hhchealth.org
− Isabella Veillette: Isabella.Veillette@hhchealth.org
▪ Organization information
− Hartford HealthCare: hartfordhealthcare.org
− Integrated Care Partners: integratedcarepartners.org
▪ Remember to complete the on-line session evaluation!
Questions?
